Discussion of public health and health care policy, from a public health perspective. The U.S. spends more on medical services than any other country, but we get less for it. Major reasons include lack of universal access, unequal treatment, and underinvestment in public health and social welfare. We will critically examine the economics, politics and sociology of health and illness in the U.S. and the world.

Thursday, March 23, 2006

Stuff that's hard to talk about

This post is inspired by Bridget Kuehn's news story in the new JAMA (off limits, as usual, to the common rabble) about fecal incontinence in women, but the issue is much broader. Kuehn begins, "Fecal incontinence can have a devastating impact on a woman's life, yet few women with this problem seek help from their physicians." New surveys find that the prevalence among women is something like 7-10%, and rises with age. Of course men can have it too, but women are at higher risk mostly because of childbirth -- especially if they've had forceps or vacuum-assisted deliveries. In one of these studies, only 10% of the women who had the condition had consulted a doctor about it in the past year. Physicians can help, depending on the cause, through medication, recommending exercise regimens, biofeedback and, as a last resort, surgery.

Well, there are a lot of important issues that people often don't talk to their doctors about - the obvious ones, of course, are sex, drugs, alcohol abuse. Slightly less obvious is domestic violence, then there's urinary as well as fecal incontinence, itching and rashes in embarassing places, hemhorroids, psychological and emotional problems (mental illness is stigmatized). You can probably think of a few more. The problem is, even though they've seen everything, doctors are still just as socially embarassed as everybody else to talk about these things, unless they've learned to get over it. Most physicians just don't ask about such issues, and if they aren't proactive, patients are unlikely to bring them up. (That explains all those erectile dysfunction ads on TV, of course. The drug companies figure the guys need a push to get over the embarassment, and they know the docs aren't going to bring it up.)

Physicians are also just about as likely as most people to be morally judgmental, and to have their particular hangups. They may not be comfortable with sexuality. (The gynecologist at the student health service where I went to college used to give the young women a lecture about the importance of chastity if they asked for contraception or he determined then to be non-virginal. So that pretty much cuts off communication.) They may be uncomfortable with homosexuality specifically. They may feel helpless or conflicted about what to do in a case of domestic violence, and as for emotional problems, they definitely don't know what to do, they just push pills.

One of the most difficult challenges in fixing medicine is finding ways to help physicians be better communicators, and this is just one more steep ridge in that broad terrain. How do you get people to talk about all that icky, humiliating stuff, and have it be okay?